Provider Demographics
NPI:1598791063
Name:CLC MEDICAL SERVICES INC.
Entity Type:Organization
Organization Name:CLC MEDICAL SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-986-4013
Mailing Address - Street 1:150 BAY ST
Mailing Address - Street 2:SUITE 915
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-2900
Mailing Address - Country:US
Mailing Address - Phone:973-986-4013
Mailing Address - Fax:
Practice Address - Street 1:150 BAY ST
Practice Address - Street 2:SUITE 915
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-2900
Practice Address - Country:US
Practice Address - Phone:973-986-4013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMP00056300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1417996OtherNATIONAL PROVIDER INDIVUA
NJQ44339Medicare UPIN
NJ1417996OtherNATIONAL PROVIDER INDIVUA